Basic Information
Provider Information
NPI: 1376214858
EntityType: 2
ReplacementNPI:  
OrganizationName: WAL-MART STORES EAST , LP
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Mailing Information
Address1: 702 SW 8TH ST
Address2:  
City: BENTONVILLE
State: AR
PostalCode: 727160445
CountryCode: US
TelephoneNumber: 4792772500
FaxNumber: 4792774331
Practice Location
Address1: 901 BOULEVARD E
Address2:  
City: YAPHANK
State: NY
PostalCode: 119807511
CountryCode: US
TelephoneNumber: 6317294041
FaxNumber:  
Other Information
ProviderEnumerationDate: 09/23/2021
LastUpdateDate: 09/23/2021
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AuthorizedOfficialLastName: LITTLE
AuthorizedOfficialFirstName: SARAH
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AuthorizedOfficialTitleorPosition: DIRECTOR OF HEALTH CARE CONTRACTING
AuthorizedOfficialTelephone: 4792772500
IsSoleProprietor:  
IsOrganizationSubpart: N
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NPICertificationDate: 09/23/2021

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
156FX1800X  N193200000X MULTI-SPECIALTY GROUPEye and Vision Services ProvidersTechnician/TechnologistOptician
332H00000X  Y SuppliersEyewear Supplier (Equipment, not the service) 

No ID Information.


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